The impact of health disparities and alcohol use on late diagnosis of HIV in Florida: Understanding missed opportunities using a statewide dataset

项目摘要/摘要 艾滋病毒的延迟诊断是一个重大的公共卫生问题，因为发病率和死亡率的风险增加 艾滋病毒传播的可能性。此Kirschstein NRSA博士前奖学金(PA-21-051)建议旨在 进行跨学科多阶段解释顺序混合方法研究，以更好地理解 与晚期HIV诊断相关的社会生态因素，检查纵向的HIV健康结果 (例如，CD4计数和病毒血症)，确定艾滋病毒检测和保健参与的促进者/障碍，以及 了解酒精的影响。这项提议响应了国家艾滋病毒/艾滋病战略，以识别遗漏的艾滋病毒/艾滋病 诊断机会，结束艾滋病毒流行倡议，以减少延迟诊断，以及国家 酒精滥用与酒精中毒研究所S了解酒精如何影响艾滋病毒的战略计划 疾病的发展。在美国，最近研究与迟发相关的因素的文献有限 人口。此外，对于晚期诊断的临床定义还没有达成共识；常见的定义 是“传统的”CD4计数200个/mm~3和“扩展”的CD_4从200个/mm~3增加到350个/mm~3， 虽然到目前为止还没有研究通过显著的协变量或纵向结果来比较这些定义。 尽管已知酒精与较差的健康和护理参与度有关，但酒精的影响也未得到充分研究。 为了实现这项研究的目标，我们将把佛罗里达州艾滋病毒携带者(PWH)的两个全州数据集联系起来： 医疗监测项目和改进的艾滋病毒/艾滋病报告系统收集的数据 2015-至2019年(N=2,000)。首先，我们将确定发病率并描述人口统计学， 有和没有多重定义的人之间的行为和心理社会差异(传统与 扩展)的后期艾滋病毒诊断。其次，我们将创建广义线性混合效应模型来进行比较 通过晚期诊断和评估重酒的潜在影响修改的纵向结果；我们将使用 这一数据的子集仅包括2015年至2019年期间诊断的数据(N=200)。最后，我们将探索 延迟诊断的原因，确定错过的检测机会，并确定新的干预点 通过对南方HIV和酒精中晚期确诊为HIV的20-25名PWH的定性访谈 研究联盟(SHARC)联系登记处(N=750)。调查结果将为干预和政策目标提供信息 通过识别健康差距和错过的检测和医疗保健机会来减少延迟诊断 订婚。该奖项的一个好处是培训为在以下领域建立成功的职业生涯奠定基础 流行病学研究和干预科学，如1)学习的优势、局限性和影响 使用多维公共卫生数据来衡量物质使用和健康结果；(2)了解 使用不同统计方法回答公共卫生纵向研究问题的理由 数据；以及(3)作为混合方法研究的一部分，领导定性数据的收集和分析，此外 培养手稿制作和演讲等技能。

Project Summary/Abstract Late diagnosis of HIV is a significant public health problem due to increased risk for morbidity and mortality and the potential for HIV transmission. This Kirschstein NRSA Predoctoral Fellowship (PA-21-051) proposal aims to conduct an interdisciplinary multiphase explanatory sequential mixed-methods study to better understand the social-ecological factors associated with late HIV diagnosis, examine longitudinal HIV health outcomes (e.g., CD4 count and viremia), identify facilitators/barriers to HIV testing and healthcare engagement, and understand the impact of alcohol. This proposal responds to the National HIV/AIDS Strategy to identify missed opportunities for diagnosis, the Ending the HIV Epidemic Initiative to reduce late diagnosis, and the National Institute on Alcohol Abuse and Alcoholism (NIAAA)’s Strategic Plan to understand how alcohol affects HIV disease progression. Recent literature investigating factors associated with late is limited in United States populations. Moreover, there is not a consensus on the clinical definition of late diagnosis; common definitions are “traditional” CD4 count<200 cells/mm3 and “expanded” CD4 from 200 cells/mm3 up to 350 cells/mm3, though no studies to date have compared these definitions by significant covariates or longitudinal outcomes. The effect of alcohol is also understudied despite known associations with worse health and care engagement. To achieve the goals of this study, we will link two statewide datasets of people with HIV (PWH) in Florida: Medical Monitoring Project (MMP) and Enhanced HIV/AIDS Reporting System (eHARS) data collected between 2015-and 2019 (N=2,000). First, we will determine the incidence and describe demographic, behavioral, and psychosocial disparities between those with and without multiple definitions (traditional vs expanded) of late HIV diagnosis. Second, we will create generalized linear mixed effect models to compare longitudinal outcomes by late diagnosis and assess potential effect modification of heavy alcohol; we will use a subset of this data including only those diagnosed between 2015-and 2019 (N=200). Finally, we will explore reasons for late diagnosis, identify missed opportunities for testing, and determine new intervention points through qualitative interviews with 20-25 PWH with late HIV diagnosis in the Southern HIV and Alcohol Research Consortium (SHARC) contact registry (N=750). Findings will inform intervention and policy targets to reduce late diagnosis by identifying health disparities and missed opportunities for testing and healthcare engagement. A benefit of this award is training to establish the foundation of a successful career in epidemiologic research and intervention science such as 1) learning strengths, limitations, and implications of using multidimensional public health data to measure substance use and health outcomes; (2) understand the rationale for using different statistical methods to answer longitudinal research questions with public health data; and (3) leading collection and analysis of qualitative data as part of a mixed-methods study, in addition to developing skills such as manuscript production and giving presentations.