Clinical and Economic Outcomes of HIV, Cigarette Smoking, and Smoking Cessation Interventions

项目摘要 在美国，艾滋病病毒携带者(PLWH)吸烟的流行率大约是这个数字的两倍 在普通人群中。烟草和艾滋病毒可能会协同作用，增加发病率和死亡率 风险。在接受抗逆转录病毒治疗(ART)的PLWH中，吸烟现在减少的预期寿命比艾滋病毒更严重 它本身。吸烟的足迹可能会随着PLWH年龄的增长而增加。 与普通人群相比，PLWH戒烟的可能性较小。戒烟 干预措施尚未在艾滋病毒护理中广泛实施，部分原因是缺乏对患者和 护理人员就该人群中的最佳戒烟策略进行了讨论。虽然艾滋病毒护理的改善已经 主要集中在新的抗逆转录病毒药物方案上，在减少 吸烟所致疾病的负担。在日益重视资源利用的环境中， 如果每个患者每年的抗逆转录病毒治疗费用超过30,000美元，则评估戒烟的成本效益 促进戒烟和减少吸烟死亡人数的干预措施至关重要。 我是一名肺病学家，有经济学背景，以前有艾滋病毒和结核病研究的经验。我 我的动机是研究有效的方法来减轻吸烟和艾滋病毒造成的疾病负担。 模拟建模可以预测行为、疾病和疾病的长期临床和经济结果 干预措施。我的长期目标是成为基于证据和模型的应用方面的世界专家 烟草、艾滋病毒和肺部交叉点的临床决策和公共卫生政策方法 疾病。在我最近的研究培训中，我通过经过验证的 和广泛出版的艾滋病毒自然历史和结果的计算机模拟，成本效益 预防艾滋病并发症(CEPAC)-美国模式。 为了实现独立，我需要在以下方面进行进一步的培训：1)建立复杂的健康行为模型；2)推导 临床和经济结果数据；以及3)设计和进行成本-效果分析。为了增强 我在这些领域的方法论技能，我已经概述了教学课程的计划，并汇编了一个 多学科指导团队。我的主要导师是罗谢尔·瓦伦斯基博士，他是一位研究艾滋病毒结果的专家 研究和模特，我的共同导师是南希·里戈蒂博士，国际戒烟权威 干预和控制政策。我的导师团队还包括行为科学(Park)方面的专家， PLWH(Triant)、肺部疾病流行病学(Christian)、慢性阻塞性肺疾病的并存 在PLWH(Medoff)，应用流行病学和生物统计学(Parker)、资源利用和卫生经济学 (研究)、数学建模和成本效益分析(Weinstein和Paltiel)，以及艾滋病毒成果 和政策(弗里德伯格)。在他们的指导下，我将利用CEPAC-US模式实现以下目标 具体研究目标：1)扩展试点美国烟草/艾滋病毒模拟模型，以考虑到 个人吸烟行为随时间的变化；2)确定临床和经济影响-包括 与心肌梗死、慢性阻塞性肺疾病和肺癌有关-吸烟 以及3)检查干预措施的成本效益，包括行为咨询和 药物治疗，以减少PLWH中与吸烟相关的发病率和死亡率。 这项研究直接回应了美国国立卫生研究院艾滋病研究办公室2016年的优先领域，该办公室认为 与艾滋病毒相关的合并症将成为一个高度优先的主题。该研究计划是创新的，将艾滋病毒与 吸烟行为、结果和成本。成本效益分析可以帮助临床医生和决策者 在长期保健干预措施中确定优先顺序。马萨诸塞州总医院、哈佛医学院和 哈佛大学陈天海公共卫生学院提供了一个独特的智力和协作环境 为了这项研究。基于我以前的研究经验和培训，现有的CEPAC-US模式，以及 通过课程作业和专家指导进行方法培训，我能够很好地完成所建议的 旨在并最终申请以烟草使用和艾滋病毒疾病为重点的R01奖。

Project Summary The prevalence of cigarette smoking among people living with HIV (PLWH) in the US is about double that among the general population. Tobacco and HIV may act synergistically to increase morbidity and mortality risks. Among PLWH on antiretroviral therapy (ART), smoking now reduces life expectancy more than HIV itself. The footprint of smoking will likely grow as PLWH age. Compared to the general population, PLWH have been less likely to quit smoking. Smoking cessation interventions have not been widely implemented in HIV care, partly due to the lack of guidance for patients and care providers on the optimum cessation strategies in this population. While improvements in HIV care have largely been focused on novel antiretroviral drug regimens, there is still much to be accomplished in reducing the burden of smoking-attributable disease. In an environment of growing attention to resource utilization, where annual ART costs exceed $30,000 per patient, evaluating the cost-effectiveness of smoking cessation interventions in promoting abstinence and reducing the toll of smoking is critically important. I am a pulmonologist with a background in economics and prior experience in HIV and tuberculosis research. I am motivated to investigate efficient ways to reduce the burden of disease caused by smoking and HIV. Simulation modeling can project long-term clinical and economic outcomes of behaviors, diseases, and interventions. My long-term goal is to become a world expert on the application of evidence- and model-based approaches to clinical decision-making and public health policy at the intersection of tobacco, HIV, and lung disease. In my recent research training, I have learned the fundamentals of disease simulation via a validated and widely-published computer simulation of HIV natural history and outcomes, the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-US model. To achieve independence, I require further training in: 1) modeling complex health behaviors; 2) deriving clinical and economic outcome data; and 3) designing and conducting cost-effectiveness analysis. To enhance my methodologic skills in these areas, I have outlined a plan of didactic coursework and assembled a multidisciplinary mentorship team. My primary mentor is Dr. Rochelle Walensky, an expert in HIV outcomes research and modeling, and my co-mentor is Dr. Nancy Rigotti, an international authority in tobacco cessation interventions and control policy. My mentorship team additionally includes experts in behavioral science (Park), comorbidities in PLWH (Triant), lung disease epidemiology (Christiani), chronic obstructive pulmonary disease in PLWH (Medoff), applied epidemiology and biostatistics (Parker), resource utilization and health economics (Resch), mathematical modeling and cost-effectiveness analysis (Weinstein and Paltiel), and HIV outcomes and policy (Freedberg). With their guidance, I will leverage the CEPAC-US model to achieve the following specific research aims: 1) to expand a pilot US tobacco/HIV simulation model to account for changes in an individual's smoking behaviors over time; 2) to determine the clinical and economic impacts – including those related to myocardial infarction, chronic obstructive pulmonary disease, and lung cancer – of smoking among PLWH; and 3) to examine the cost-effectiveness of interventions, including behavioral counseling and pharmacotherapy, to reduce smoking-associated morbidity and mortality among PLWH. This research responds directly to the 2016 priority areas of the NIH Office of AIDS Research, which considers HIV-associated comorbidities to be a high priority topic. The research plan is innovative by integrating HIV with smoking behaviors, outcomes, and costs. Cost-effectiveness analysis can help clinicians and policymakers prioritize among interventions for PLWH. Massachusetts General Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health provide an exceptional intellectual and collaborative environment for this research. Building on my prior research experience and training, the existing CEPAC-US model, and methodologic training via coursework and expert mentorship, I am well-positioned to accomplish the proposed aims and ultimately apply for an R01 award focused on tobacco use and HIV disease.