Implementation science research on PrEP delivery and costing within MAT and NSP services for PWUD in Uganda

摘要 在过去十年中，乌干达的吸毒人数增加了10倍 （PWUD）和通过共用注射设备传播艾滋病毒的风险，这是这种情况下的常见做法 很少有清洁设备。据估计，艾滋病毒在残疾人和女童中的流行率高达 45%，强调了艾滋病毒治疗和预防对残疾人的重要性， 包括口服暴露前预防（PrEP）。PrEP被纳入艾滋病毒预防指南， 乌干达在2016年和PEPFAR资金一直支持有针对性地向包括PWUD在内的关键人群推广。 然而，目前正在接受PrEP的人中有不到250人被确定为PWUD，这表明预防方面存在很大差距 并有机会优化PWUD的PrEP交付。对于感染艾滋病毒的PWUD，抗逆转录病毒治疗 已被纳入药物辅助治疗（MAT）计划和针头和注射器交换计划 (NSP)通过利用同情成瘾并有经验打击相关耻辱的提供者， 吸毒我们假设，通过整合PrEP交付，可以对PrEP进行类似的方法 进入MAT和NSP计划，我们提出了一个分阶段的方法来进行形成性的工作，并完善 两个综合方案（PrEP + MAT和PrEP + NSP），以试点这些方案并评估PrEP吸收情况， 保留和遵守，并进行成本计算研究，直接为政策指导提供信息。我们的工作 在开展工作时，将注意综合执行框架内的几个结构 与最大的减少危害网络-警察-的成员一起，以参与性方法进行研究和扎根 在乌干达担任项目顾问。具体而言，我们的目标是：1）进行定性研究， 探讨艾滋病毒预防服务的偏好和愿意使用/开PrEP的PWUD， a）口服PrEP和B）乌干达坎帕拉PWUD服务的提供者; 2）完善社区方案- 基于NSP + PrEP和基于设施的MAT + PrEP; 3）比较PrEP吸收，保留和依从性， PrEP被整合到基于社区的NSP中，而不是基于设施的MAT中，以PWUD;和4）估计 计划成本和进行预算影响分析，将PrEP纳入我们的MAT和NSP计划。 冲击拟议的工作将提供强有力的证据，说明如何优化综合减灾， 在乌干达和类似环境中向PWUD提供PrEP。乌干达武装部队成员直接参与， 卫生部对我们的调查小组，我们的调查结果将立即用于政策指导方针， 指导方案扩大。这项工作将是相关的美国和全球作为一个示范的共址 为PWUD提供减少伤害和艾滋病毒预防服务，并将提供有关PrEP的首批数据 在PWUD中的坚持和保留。

ABSTRACT In the past decade, Uganda seen increases – as large as 10-fold – in the number of people who use drugs (PWUD) and the risk for HIV transmission through shared injection equipment, a common practice in this setting with low access to clean equipment. HIV prevalence among PWUD has been estimated to be as high as 45%, highlighting the importance of widescale access to HIV treatment and prevention for PWUD, including oral pre-exposure prophylaxis (PrEP). PrEP was integrated into HIV prevention guidelines in Uganda in 2016 and PEPFAR funding has been supporting targeted rollout to key populations, including PWUD. However, <250 people currently accessing PrEP have identified as PWUD, indicating a large gap in prevention and an opportunity to optimize PrEP delivery for PWUD. For PWUD living with HIV, antiretroviral treatment has been integrated into medication assisted treatment (MAT) programs and needle and syringe exchange programs (NSP), by leveraging providers who empathize with addiction and have experience combating stigma associated with drug use. We hypothesize that a similar approach can be done for PrEP by integrating PrEP delivery into MAT and NSP programs and we proposed a staged approach to conduct formative work and refine two integrated programs (PrEP + MAT and PrEP + NSP), to pilot these programs and assess PrEP uptake, retention, and adherence and to conduct costing research to directly inform policy guidance. Our work will be conducted with attention to several constructs within the Consolidated Framework for Implementation Research and grounded in a participatory approach with members of the largest harm reduction network, police force, and PWUD in Uganda as project advisors. Specifically, we aim to: 1) conduct qualitative research to explore preferences for HIV prevention services and willingness to use/prescribe PrEP among PWUD and providers of a) oral PrEP and b) services for PWUD in Kampala, Uganda; 2) refine programs for community- based NSP + PrEP and facility-based MAT + PrEP; 3) compare PrEP uptake, retention, and adherence when PrEP is integrated into community-based NSP versus facility-based MAT to PWUD; and 4) estimate the programmatic costs and conduct budget impact analysis for integrating PrEP into our MAT and NSP programs. Impact. The proposed work will provide robust evidence about how to optimize integrated harm reduction and PrEP delivery to PWUD in Uganda and similar settings. With direct engagement from members of the Ugandan Ministry of Health on our investigative team, our findings will be immediately useful for policy guidelines and to guide programmatic scale-up. This work will be relevant to the US and globally as a demonstration of co-located harm reduction and HIV prevention services for PWUD and it will provide some of the first data on PrEP adherence and retention among PWUD.