Viral Suppression for People with HIV with Low Incomes: Study of Disparities, Health Equity, and Best Practices

项目总结/摘要 艾滋病毒感染者（PWH）需要持续获得护理和抗逆转录病毒治疗（ART），以实现持续的 病毒抑制（VS）对个人健康（降低发病率、合并症和死亡率）和公众健康至关重要 健康（预防艾滋病毒的传播）。美国（US）在艾滋病毒VS 对于依赖国家艾滋病药物援助计划（ADAP）的低收入PWH，范围为53%至99%。 ADAP以24亿美元的年度预算支持美国26%的PWH。作为美国艾滋病医疗保健的一个重要组成部分， 在提供安全网的情况下，ADAP通过直接提供或通过ADAP补贴的保险计划提供免费的抗逆转录病毒治疗。 ADAP的实施情况差异很大，因为各州的ADAP在卫生方面具有决策灵活性， 护理提供方案和政策。此外，ADAP如何在不同的子组中执行仍然未知。 了解ADAP如何优化VS可以降低医疗成本，因为每一次艾滋病毒感染都可以避免 节省了40万2千美元为了支持结束美国的艾滋病毒流行，我们的长期目标是利用流行病学，包括 因果推理框架和定性方法，以确定如何改善所有PWH的VS，包括那些 通过医疗保健服务项目，在关注差异和健康公平的同时，我们的过度- 研究的问题是为低收入的威尔斯亲王医院提供什么具体的医疗服务计划和政策 增加持续VS率并减少与种族/族裔有关的VS差异？我们的团队研究了ADAP 自2014年起我们的研究结果已被用于倡导成功改变医疗保健法律。校长 调查员，唯一的研究人员与联邦基金，以研究这方面的艾滋病毒医疗保健提供，和 跨学科小组将利用新的因果流行病学和定性方法的专门知识。我们有搭档- 与全国州和地区艾滋病主任联盟（NASTAT）和六个州卫生部门合作 提供对多个州个人级数据的访问（占ADAP客户端的20%，包括VS的ADAP 率极端），并为全国性的研究，我们将采访艾滋病/ADAP领导。我们将完成以下工作： 目标1：我们将分解与种族/民族相关的持续VS差异。我们将量化调解 一个可修改的因素，ADAP医疗保健提供计划的影响。目标2：我们将量化潜在改进 在由状态ADAP客户端混合通知的各个状态ADAP的持续VS中。对所有状态进行模拟 ADAP，我们将估计ADAP客户更改为特定ADAP计划对持续VS的影响。目的 3：我们将在全国范围内采访艾滋病/ADAP主任。通过定性分析，我们将... 使ADAP计划和政策合理化，以改善VS和提高健康公平性。成功完成本 这项工作将提供证据，为州/联邦法规和资源优先级提供信息， 人们实现VS和阻断艾滋病毒的传播。我们的研究结果将允许国家ADAP，倡导者，政策- 制造商，并结束艾滋病毒流行病倡议领导人采用我们的研究确定的最佳做法， 制定新的干预措施（法律、指导、资金），以优化VS-将数据转化为政策和行动。

PROJECT SUMMARY/ABSTRACT People with HIV (PWH) need consistent access to care and antiretroviral therapy (ART) to achieve the sustained viral suppression (VS) critical for individual health (reduced morbidity, comorbidities, and mortality) and public health (preventing transmission of HIV). The United States (US) has significant geographic disparities in HIV VS for PWH with low incomes who rely on state AIDS Drug Assistance Programs (ADAPs), ranging 53% to 99%. ADAPs support 26% of PWH in the US with a $2.4 billion annual budget. As a key part of the US HIV healthcare delivery safety net, ADAPs provide free ART by direct provision or through ADAP-subsidized insurance plans. ADAP implementation varies widely because individual state ADAPs have decision-making flexibilities for health- care delivery programs and policies. Additionally, how ADAPs perform for different subgroups remains unknown. Understanding how ADAPs can optimize VS could reduce healthcare costs, because each HIV infection averted saves $402,000. To support ending the US HIV epidemic, our long-term goal is to use epidemiologic, including causal inference framework, and qualitative methods, to identify how to improve VS for all PWH, including those with low incomes, through healthcare delivery programs. With a focus on disparities and health equity, our over- arching research question is what specific healthcare delivery programs and policies for PWH with low incomes increase sustained VS rates and reduce VS disparities related to race/ethnicity? Our team has studied ADAPs since 2014. Our study results have been used to advocate to successfully change healthcare laws. The Principal Investigator, the only researcher with federal funding to study this aspect of HIV healthcare delivery, and the interdisciplinary team will use expertise in novel causal epidemiology and qualitative methods. We have partner- ships with the National Alliance of State & Territorial AIDS Directors (NASTAD) and six state health departments providing access to multistate individual-level data (comprising 20% of ADAP clients; including ADAPs at VS rate extremes), and for a national study, we will interview AIDS/ADAP leadership. We will complete the following: Aim 1: we will decompose disparities in sustained VS related to race/ethnicity. We will quantify the mediating effect of a modifiable factor, ADAP healthcare delivery programs. Aim 2: we will quantify potential improvements in sustained VS for individual state ADAPs informed by state ADAP client mix. Using simulation for all state ADAPs, we will estimate the impact on sustained VS of ADAP clients changing to specific ADAP programs. Aim 3: we will perform interviews of AIDS/ADAP Directors across the nation. Using qualitative analyses, we will iden- tify the ADAP programs and policies that improve VS and improve health equity. Successful completion of this work will provide evidence to inform state/federal regulation and resource prioritization toward the goal of helping people achieve VS and interrupting HIV transmission. Our findings would allow state ADAPs, advocates, policy- makers, and Ending the HIV Epidemic initiative leaders to adopt best practices identified from our study and to develop new interventions (laws, guidance, funding) to optimize VS- translating data into policy and action.