Scaling Low-Barrier Care to Engage People with Complex Needs in HIV Treatment

让最脆弱的艾滋病毒感染者接受治疗，是努力结束艾滋病毒流行病的核心。低- 屏障护理（LBC）是一种基于证据的多组分干预措施，包括无障碍医疗 保健、鼓励门诊和抑制病毒、大力支持解决健康的社会决定因素， 多部门服务协调。西雅图的Max诊所是LBC的旗舰诊所， 在有复杂护理障碍的人群中改善病毒抑制，包括不稳定的住房，物质 使用和精神健康障碍。扩大LBC是结束艾滋病毒流行病（EHE）计划的核心 县，华盛顿。这项为期5年的提案的总体目标是研究LBC在金郡的扩张， 确定促进LBC实施的因素，并为在其他EHE中扩大干预措施做好准备 辖区该小组将采用多方面的实施战略，建立和改善两个新的LBC 除了Max Clinic之外，我们将使用覆盖范围、有效性、采用、实施和 维护（RE-AIM）框架和结构化工具，以评估干预适应性和可扩展性。为宗旨 1，我们将使用基于人口的 观察性开放队列设计。对于目标2，我们将在 金郡，包括干预适应，组织战略，以克服障碍，和成本。使用 报告调整和修改框架-增强版（FRAME），我们将进行焦点小组讨论， 在基线时与LBC诊所和卫生部门的主要利益相关者进行讨论， 在四年内每隔六个月进行一次评估，以描述干预措施的适应性， 实施和维护策略。我们将量化LBC扩张的成本， 部门和医疗保健组织的角度使用微观成本计算方法。对于目标3，我们将评估 LBC干预的可扩展性，并确定一个由卫生部门和诊所领导人组成的联盟，以扩展- 在美国各地优先考虑EHE第一阶段资金的城市和州建立LBC。 NASTAT（国家和地区艾滋病主任协会）确定卫生部门艾滋病毒 支持LBC实施的项目负责人，并与他们合作，招募Ryan的领导人 白人资助的艾滋病诊所或社区卫生中心诊所。我们将对双方进行深入采访 卫生部门和诊所领导使用干预可扩展性评估工具（ISAT）， 在每个地方的情况下评估LBC实施考虑因素。预期成果：我们的成果将 指导LBC实施的优化，为干预措施的调整提供信息，并为战略 在该国其他地区扩大LBC的规模，这将反过来推动实现EHE目标的进展。

Engaging the most vulnerable people with HIV in treatment is central to efforts to end the HIV epidemic. Low- barrier care (LBC) is an evidence-based multicomponent intervention that includes walk-in access to medical care, incentives for clinic visits and viral suppression, intensive support to address social determinants of health, and multisectoral service coordination. The Max Clinic in Seattle is a flagship LBC clinic that has substantially improved viral suppression among people with complex barriers to care, including unstable housing, substance use, and mental health disorders. Expanding LBC is central to the Ending the HIV Epidemic (EHE) plan in King County, Washington. The overall goals of this 5-year proposal are to study LBC expansion in King County, identify factors that facilitate LBC implementation, and prepare for the intervention’s scale-up in other EHE jurisdictions. The team will employ a multifaceted implementation strategy to establish and improve two new LBC clinics in addition to the Max Clinic. We will use the Reach, Effectiveness, Adoption, Implementation & Maintenance (RE-AIM) framework and structured tools to assess intervention adaptation and scalability. For Aim 1, we will evaluate the reach and effectiveness of LBC expansion in King County using a population-based observational open cohort design. For Aim 2, we will describe the implementation and maintenance of LBC in King County, including intervention adaptations, organizational strategies to overcome barriers, and costs. Using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME), we will conduct focus group discussions with key stakeholders in the LBC clinics and the health department at baseline and conduct brief re- assessments in six-month intervals over four years to describe intervention adaptations and elucidate implementation and maintenance strategies. We will quantify the costs of LBC expansion from the health department and healthcare organization perspectives using micro-costing methods. For Aim 3, we will assess the scalability of the LBC intervention and identify a consortium of health department and clinic leaders to scale- up LBC in cities and states prioritized for the first phase of EHE funding throughout the U.S. We will partner with NASTAD (the National Association of State & Territorial AIDS Directors) to identify health department HIV program leaders supportive of LBC implementation, and in collaboration with them, recruit leaders of Ryan White-funded HIV Clinics or Community Health Center clinics. We will conduct in in-depth interviews with both the health department and clinic leaders using the Intervention Scalability Assessment Tool (ISAT) for applied assessment of LBC implementation considerations in each local context. Expected Outcome: Our results will guide optimization of LBC implementation, inform intervention adaptations, and lay the groundwork for strategic scale-up of LBC in other parts of the country, which will in turn, advance progress toward achieving EHE goals.