Impact of Representative Payee Services on ART Adherence Among Marginalized People Living with HIV/AIDS

项目摘要/摘要 缺乏结构性干预措施来提高抗逆转录病毒疗法(ART)的依从性，这代表着 错失了减少艾滋病毒健康差距的机会。经济上的劣势会导致贫穷 通过有限的社会资源等中介因素，重复用药依从性和临床结果 住房不稳定的周期，财务不安全造成的高度压力，以及缺乏应对资源 有了这些要求。治疗为预防是提高临床疗效的重要方法 艾滋病毒/艾滋病患者(PLWHA)和减少二次传播；然而，要想采取这种方法， 优化后，必须提高和维持抗逆转录病毒治疗的坚持率。以客户为中心的代表收款人是 一种结构性干预措施，通过修改 在社会保障管理局内执行一项长期政策，其中一个组织是 被授权作为客户的收款人。这项研究的中心假设是，通过帮助客户支付 房租等账单如期出台，住房稳定性将改善，财政压力将会减轻。通过减少 在长期经济压力和频繁的住房损失威胁下生活的认知负担，客户可以致力于 有更多的时间和精力来预约就诊和坚持服药。进一步假设 这些变化将提高患者的健康行为自我效能感、护理保留率、服药依从性、 和病毒载量。这些假设将通过以下具体目标进行检验：(1)进行随机化 对照试验(n=320)，以测试以客户为中心的代表收款人对ART依从性和病毒载量的影响 在经济上处于不利地位和住房不稳定的PLWHA中。临床依从性将是 通过包括处方续订数据在内的行为和生物测量进行比较，自我报告 接受干预的患者与接受标准干预的患者的预约遵从性和病毒载量 关爱。(2)测试与以客户为中心的代表收款人相关的基本机制，这些机制有助于 服药依从性和病毒抑制率的变化。这将通过使用量化 (中介分析)和定性(半结构访谈)方法检验假设的中介变量 服药依从性和病毒抑制包括财务和住房不稳定、财务压力、自我 对健康行为的有效性，以及对护理的保留。(3)评估客户的成本及成本效益- 中心代理收款人模型。将进行经济分析，以模拟干预的影响 与标准护理相比，调整后的生命年数和避免新感染的情况有所改善。这 方法是创新的，因为它提供了一种结构性干预，通过解决 经济不安全的影响，只需要很低的财务投资，并且可以与现有的临床分层 服务。此外，它是高度可扩展的，因为它建立在社会保障体系内实践中的当前政策之上 系统。

Project Summary/Abstract There is a lack of structural interventions to improve antiretroviral therapy (ART) adherence, which represents missed opportunities to reduce HIV health disparities. Economic disadvantage can contribute to poor medication adherence and clinical outcomes through mediators such as limited social resources, repeated cycles of housing instability, high levels of stress caused by financial insecurity, and lack of resources to cope with these demands. Treatment as Prevention is an important method of improving clinical outcomes for people living with HIV/AIDS (PLWHA) and reducing secondary transmissions; however, for this approach to be optimized, rates of ART adherence must be improved and sustained. Client-Centered Representative Payee is a structural intervention that provides financial management support to PLWHA by modifying the implementation of a long-standing policy within the Social Security Administration, in which an organization is authorized to serve as the client's payee. The central hypothesis of this study is that by helping clients to pay rent and other bills on time, housing stability will improve and financial stress will decrease. By reducing the cognitive burden of living with chronic financial stress and frequent threats of housing loss, clients can devote more time and attention to medical appointments and medication adherence. It is further hypothesized that these changes will improve clients' self-efficacy for health behaviors, retention in care, medication adherence, and viral loads. These hypotheses will be tested via the following specific aims: (1) Conduct a randomized controlled trial (n=320) to test the effect of Client-Centered Rep Payee on ART adherence and viral load among PLWHA who are economically disadvantaged and unstably housed. Clinical adherence will be compared through behavioral and biological measures including prescription refill data, self-reported appointment adherence, and viral load for patients receiving the intervention versus those receiving standard of care. (2) Test underlying mechanisms associated with Client-Centered Rep Payee that contribute to changes in medication adherence and viral suppression rates. This will be accomplished via use of quantitative (mediation analysis) and qualitative (semi-structured interview) methods to test hypothesized mediators of medication adherence and viral suppression including financial and housing instability, financial stress, self- efficacy for health behaviors, and retention in care. (3) Assess the cost and cost-effectiveness of the Client- Centered Rep Payee model. An economic analysis will be conducted to model the impact of the intervention as compared with standard of care on quality adjusted life years as well as new infections averted. This approach is innovative because it offers a structural intervention to improve adherence by addressing the effects of economic insecurity, requires low financial investment, and can be layered with existing clinical services. Further, it is highly scalable as it builds on a current policy in practice within the Social Security system.