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增加了并发酒精和药物依赖的风险（分别>50%和>30%），这反过来又增加了艾滋病毒性风险行为（HSB）的风险。一项关于艾滋病毒预防的荟萃分析发现，很少有干预措施能解决创伤暴露、心理健康或SUD等风险因素，而未能做到这一点的干预措施的避孕套使用效果较差，对创伤后应激障碍患者的效果也较差。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）社区在未经治疗的PTSD，SUD和艾滋病毒/性传播感染风险方面的风险不成比例。通过物质使用自我治疗PTSD会导致SUD的发展，并加剧HSB。因此，PTSD的治疗也减少了个体的物质使用，可以防止HIV风险行为的开始或复发。同样，通过增加减少使用的动机和加强应对策略来直接干预以减少物质使用，应该可以预防SUD的发展，并改善HSB和PTSD。因此，解决PTSD或物质使用可能有效地防止HSB。这项研究建立在一个为期8年的以社区为基础的参与性伙伴关系的基础上，与部落民族充分合作，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物质使用来预防艾滋病毒/性传播疾病的性风险行为。我们将评估叙事暴露疗法（NET）与动机访谈与技能培训（MIST）在艾滋病毒/性传播感染预防中的作用。AI长老和社区领袖坚持认为，“我们可以继续提供物质使用或性风险计划，但直到我们找到根本原因-创伤-然后我们将继续用一种避免手段取代另一种手段”。这项研究将有助于解决这个社区产生的临床和实证问题。总体目标是比较两种循证治疗方法，每种方法都针对不同的HSB因果途径。NET解决PTSD预防SUD和HSB。MIST解决了防止SUD和HSB的物质滥用问题。目的1：检查PTSD与以物质使用为重点的干预措施，以防止HSB。我们将进行一项两组随机比较有效性试验，在有PTSD症状的AI男性和女性中比较NET（n=100）和MIST（n=100）。我们将评估减少PTSD严重程度和物质使用的影响（例如，频率、数量、意图、复发和开始使用）（例如，在术后、6个月和12个月随访时的伴侣数量、使用药物时的性行为、无保护性行为和与高风险伴侣的性行为）。目标二：研究HSB治疗结果的理论中介因素，包括情绪调节、认知再评价、应对自我效能、沟通技巧、自信心和社区联系力。

 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.