Preventing HIV among Native Americans through the treatment PTSD & substance use

 描述(由申请人提供)：未经治疗的创伤后应激障碍会增加同时发生酒精和药物依赖的风险(分别为50%和30%)，这反过来又会增加HIV性危险行为(HSB)的风险。一项对艾滋病毒预防的荟萃分析发现，很少有针对创伤暴露、心理健康或SUD等风险因素的干预措施，而未能做到这一点的干预措施会导致较差的避孕套使用结果，对患有创伤后应激障碍的人效果较差。从公共卫生的角度来看，解决创伤后应激障碍和物质使用障碍是预防艾滋病毒/性传播感染的一个重要但被忽视的手段。美国印第安人(AI)社区面临着不成比例的PTSD、SUD和HIV/STI风险。通过物质使用而自我用药的创伤后应激障碍会导致肥皂泡的发展，并加剧HSB。因此，治疗创伤后应激障碍，同时减少个人的药物使用，可能会防止艾滋病毒危险行为的开始或复发。同样，通过增加减少药物使用的动机和加强应对策略来直接干预以减少药物使用，应该可以防止SUD的发展，并改善HSB和PTSD。因此，解决创伤后应激障碍或药物使用问题可能会有效地预防HSB。这项研究建立在与部落民族充分合作的为期8年的社区参与性伙伴关系的基础上，提出了一项为期5年的双臂随机比较有效性试验，以评估通过直接解决创伤后应激障碍或药物使用来预防艾滋病毒/性传播感染的性危险行为。我们将在HIV/STI预防方面评估叙述性暴露疗法(Net)和带有技能培训的激励性访谈(MIST)。AI长老和社区领袖坚持认为，“我们可以继续提供药物使用或性风险项目，但在我们找到根本原因--创伤--之前，我们将继续用一种避免方式来取代另一种方式”。这项研究将有助于解决这一社区产生的临床和经验问题。总体目标是比较两种基于证据的治疗，每种治疗都针对不同的HSB原因途径。网络地址PTSD，防止SUD和HSB。MIST解决物质滥用问题，防止SUD和HSB。目标1：研究创伤后应激障碍与以药物使用为重点的干预措施对预防高血压病的作用。我们将在有创伤后应激障碍症状的AI男性和女性中进行一项双臂随机比较有效性试验，比较Net(n=100)和MIST(n=100)。我们将评估创伤后应激障碍严重程度和药物使用(例如，频率、数量、意图、复发和开始使用)在后、6和12个月的随访中对HSB(例如，伴侣数量、使用药物时的性行为、无保护措施的性行为和与高危伴侣的性行为)的影响。目的2：考察情绪调节、认知再评价、应对自我效能感、沟通技能、自信和社区连通性等治疗对HSB结果的理论中介作用。

 DESCRIPTION (provided by applicant): Untreated PTSD elevates risk of concurrent alcohol and drug dependence (>50% and >30% respectively), which in turn elevates risk of HIV sexual-risk behavior (HSB). A meta-analysis of HIV prevention, found few interventions address risk factors such as trauma exposure, mental health, or SUD and interventions which failed to do so had poorer condom use outcomes and were less effective for those with PTSD. From a public health perspective addressing PTSD and substance use disorders (SUD) is an important but overlooked means of preventing HIV/STI. American Indian (AI) communities are at disproportionate risk for untreated PTSD, SUD and HIV/STI risk. Self-medication of PTSD through substance use leads to development of SUDs, and exacerbates HSB. Therefore, treatment of PTSD that also decreases substance use in individuals may prevent the initiation or relapse of HIV risk behaviors. Similarly, directly intervening to reduce substance use via increasing motivation to decrease use and enhance coping strategies should prevent SUD development, and improve HSB and PTSD. Thus addressing PTSD or substance use may effectively prevent HSB. Built on an 8-year community-based participatory partnership, in full collaboration with the Tribal Nation, this study proposes a 5-year two-arm randomized comparative effectiveness trial to evaluate prevention of HIV/STI sexual risk behavior by directly addressing PTSD or substance use. We will evaluate Narrative Exposure Therapy (NET) versus Motivational Interviewing with Skills Training (MIST) in HIV/STI prevention. AI elder and community leaders have insisted that "we can keep providing substance use or sexual risk programs but until we get to the underlying cause - trauma - then we'll keep replacing one means of avoidance for another". This study will help address this community-generated clinical and empirical question. The overall goal is to compare two evidence based treatments, each addressing a different HSB causal pathway. NET addresses PTSD preventing SUD and HSB. MIST addresses substance misuse preventing SUD and HSB. Aim 1: To examine a PTSD versus a substance use-focused intervention to prevent HSB. We will conduct a two-arm randomized comparative effectiveness trial comparing NET (n=100) to MIST (n=100) among AI men and women with PTSD symptoms. We will evaluate the effect of reductions in PTSD severity and substance use (e.g., frequency, quantity, intentions, relapse, and initiation of use) on HSB (e.g., number of partners, sex while using substances, unprotected sex, and sex with high-risk partners) at post, 6, and 12-month follow-up. Aim 2: To examine theoretical mediators of treatment on HSB outcomes including emotional regulation, cognitive reappraisals, coping self-efficacy, communication skills, assertiveness, and community connectiveness.