Impacts of universal access to HIV/AIDS care among HIV+ injection drug users

项目摘要/摘要 二十年来，有效的抗逆转录病毒疗法(ART)被开发出来，用于HIV感染，HIV阳性 使用非法药物(PWUD)的人在艾滋病毒治疗结果方面继续存在差异。 尽管高强度非法药物使用对获得和遵守抗逆转录病毒治疗的有害影响是显而易见的，但 参与和保留艾滋病毒护理的社会、结构和经济障碍仍然不完全 描述，迫切需要确定艾滋病毒和成瘾的治疗方面，以促进 最佳艾滋病毒治疗结果。 与此同时，人们越来越认识到与艾滋病毒相关的共病的重要性， 合并感染和并发症--特别是免疫功能障碍、慢性炎症和早产 老龄化对艾滋病毒疾病结果的影响，即使在艾滋病毒阳性的人中也是如此，最好从事抗逆转录病毒治疗。虽然 一些合并症，如丙型肝炎病毒合并感染，对HIV阳性的PWUD的影响是好的 描述，我们不知道有任何纵向研究使用有效的措施，包括艾滋病毒-和非- 与艾滋病毒相关的临床生物标志物，系统地调查艾滋病毒疾病的严重程度，以及非法药物的影响 免费环境下艾滋病毒阳性PWUD的使用情况及相关的社会、结构和经济因素 全民医疗，包括所有抗逆转录病毒药物和成瘾治疗药物。 因此，在这一应用中，我们提出了对个人、社会、 PWUD中艾滋病毒治疗和疾病结局的结构和经济决定因素。具体来说， 通过更新为社区招募的1000多名长期社区招募的预期队列提供资金 将HIV阳性的PWUD与加拿大温哥华的全面临床监测数据联系起来，我们建议： 分析新出现的艾滋病毒和成瘾治疗方法的实施、吸收和影响 实现和维持最佳艾滋病毒治疗和疾病结果；调查 关于艾滋病毒成瘾治疗的既有和新出现的非法药物使用模式和不断演变的方法 治疗和疾病结果；探索社会、结构和经济力量之间的相互关系 和非法药物使用模式对艾滋病毒疾病结果的影响；并继续作为NIDA资助的队列，这是一个 艾滋病毒获取的一系列流行病学、系统发生/生物信息学和基础研究的平台， 在使用非法药物的人群中的传播和发病机制。 这项更新我们研究计划的建议利用了 当地环境，包括：普遍获得免费医疗的集中方案，允许 完全确定临床数据而不受经济能力的影响；正在进行的 为残障人士制定一系列创新的艾滋病毒和成瘾方案，包括在 艾滋病毒诊断、以减少危害为基础的艾滋病毒预防和治疗支助；以及 管理阿片类药物和兴奋剂使用障碍。我们的建议与最近要求高度优先的呼声非常一致 通过以下方式减少HIV阳性PWUD患者在艾滋病毒治疗和疾病结局方面的差异的研究 促进参与和保留艾滋病毒护理并减少合并症影响的证据， 并发症和合并感染。

PROJECT SUMMARY / ABSTRACT Two decades since the development of effective antiretroviral therapy (ART) for HIV infection, HIV-positive people who use illicit drugs (PWUD) continue to experience persistent disparities in HIV treatment outcomes. Although the deleterious impact of high-intensity illicit drug use on access and adherence to ART is clear, the social, structural and economic barriers to engagement and retention in HIV care remain incompletely described, and there is an urgent need to identify aspects of treatment for HIV and addiction that promote optimal HIV treatment outcomes. At the same time, there is an increasing appreciation of the importance of HIV-associated comorbidities, coinfections and complications—especially immunologic dysfunction, chronic inflammation and premature aging—on HIV disease outcomes, even among HIV-positive individuals optimally engaged in ART. Although the impact of some comorbidities, such as hepatitis C virus co-infection, on HIV-positive PWUD are well described, we are unaware of any longitudinal study using a validated measure incorporating HIV- and non- HIV-related clinical biomarkers to systematically investigate HIV disease severity, and the impact of illicit drug use and related social, structural and economic factors, among HIV-positive PWUD in a setting of no-cost universal medical care including all ART and medications for addiction treatment. Thus, in this application, we propose novel and significant investigations into the individual, social, structural and economic determinants of HIV treatment and disease outcomes among PWUD. Specifically, through the renewal of funding for a longstanding community-recruited prospective cohort of more than 1000 HIV-positive PWUD linked to comprehensive clinical monitoring data in Vancouver, Canada, we propose to: analyze the implementation, uptake and impact of new and emerging treatment for HIV and addiction on the achievement and maintenance of optimal HIV treatment and disease outcomes; investigate the impacts of established and emerging illicit drug use patterns and evolving approaches to addiction treatment on HIV treatment and disease outcomes; explore the interrelationships between social, structural and economic forces and illicit drug use patterns on HIV disease outcomes; and continue to serve as a NIDA-funded cohort that is a platform for a range of epidemiological, phylogenetic/bioinformatic and basic research into HIV acquisition, transmission and pathogenesis among people who use illicit drugs. This proposal to renew our research program exploits several established and emerging facets of the local environment, including: a centralized program of universal access to no-cost medical care, allowing for the complete ascertainment of clinical data free of the confounding influence of financial ability; the ongoing development of a range of innovative HIV and addiction programs for PWUD, including initiation of ART upon HIV diagnosis, harm-reduction-based HIV prevention and treatment supports; and novel approaches to manage opioid and stimulant use disorders. Our proposal is well aligned with recent calls for high-priority research to reduce disparities in HIV treatment and disease outcomes among HIV-positive PWUD through evidence to promote engagement and retention in HIV care and reduce the effect of comorbidities, complications and coinfections.