Promoting Sustained Viral Suppression Through Implementation of an Adapted Evidence-Informed Low-Barrier Care Model in a System of HIV Primary Care Clinics

项目摘要/摘要 如果艾滋病毒携带者(PWH)在美国结束艾滋病毒流行(EHE)的目标无法实现 不要实现持续的病毒抑制(VS)。然而，美国超过一半的威尔斯亲王没有收到 定期艾滋病毒护理，主要是由于社会和结构性因素，如耻辱和歧视、贫困和护理 复杂性，以及精神健康和药物滥用等条件。提供护理服务的其他方法， 尤其是对于经历复合障碍的PWH，需要在持续护理和VS方面缩小差距。 低障碍护理(LBC)是一套制定的实施和护理参与战略 具体解决威尔斯亲王医院遇到的具有复杂需求的障碍，并已被证明显著 改善这一人群中的VS。然而，最初的LBC独立诊所模式可能会面临挑战 在可伸缩性方面，由于可行性和在大范围内对PWH的覆盖有限。相比之下，调整LBC战略 整合到现有的艾滋病毒初级保健地点有可能促进更多地使用这一有希望的 艾滋病毒护理的典范，同时也让更多的威尔斯亲王医院参与到未解决的需求中。这件事的首要目标是 建议是评估在12个艾滋病毒感染者系统中调整后的LBC战略的实施和有效性 由芝加哥公共卫生部(CDPH)资助的以人口为中心的健康之家(PCHH)使用 务实的试验设计。在《环境影响报告书》框架的指导下，我们将通过三个具体目标实现这一目标： (1)利用学习促进PCHH采用、适应和实施LBC战略 协作性。学习协作是广泛使用的、基于证据的实施策略。跟随 最佳做法，一名首席推动者和专题专家将帮助多氯环己烷探索和准备 在实施LBC战略的同时，训练有素的实践教练将提供以下技术援助 在每个站点实施。CDPH对将LBC战略整合到PCHH中具有浓厚的兴趣，并将两者 授权PCHH参与协作学习，并通过额外的 资金问题。我们将使用混合方法评估LBC战略的采用和实施过程。 (2)评估综合LBC战略在改善现场和系统范围内的有效性 持续护理和VS。使用单臂试验前设计，我们将评估护理中的保留率 在LBC战略升级后的两年里，VS有所改善。我们还将研究上下文因素 和实施保真度，使用混合方法来解释多氯环己烷结果的差异性。 (3)评估初级卫生保健机构LBC战略的实施成本和维持情况。我们将研究 随时间推移的实施成本和使用混合方法的维持计划。 我们的建议直接响应RFA-AI-21-024，并与NIH艾滋病研究办公室的 高度重视实施科学，以改善艾滋病毒服务的提供和减少治疗方面的差距。 这项研究的结果将有助于在新的环境下使用LBC策略，以帮助具有复杂需求的威尔斯亲王医院。

PROJECT SUMMARY/ABSTRACT The goal to end the HIV epidemic (EHE) in the United States cannot be achieved if people with HIV (PWH) do not achieve sustained viral suppression (VS). However, more than half of PWH in the US do not receive regular HIV care, due largely to social and structural factors like stigma and discrimination, poverty, and care complexity, as well as conditions like mental health and substance abuse. Additional approaches to care delivery, especially for PWH experiencing compounding barriers, are needed to close the gap in sustained care and VS. Low-barrier care (LBC) is a package of implementation and care engagement strategies developed specifically to address barriers experienced by PWH with complex needs and has been shown to significantly improve VS among this population. The original model of standalone LBC clinics, however, may have challenges in scalability due to feasibility and limited reach to PWH within large areas. In contrast, adapting LBC strategies for integration into existing HIV primary care sites has the potential to facilitate greater use of this promising model of HIV care while also engaging more PWH with unaddressed needs. The overarching goal of this proposal is to evaluate the implementation and effectiveness of adapted LBC strategies in a system of 12 HIV population-centered health homes (PCHHs) funded by the Chicago Department of Public Health (CDPH) using a pragmatic trial design. Guided by the EPIS framework, we will achieve this goal through three specific aims: (1) Facilitate adoption, adaptation, and implementation of LBC strategies by PCHHs using a learning collaborative. Learning collaboratives are widely used, evidence-based implementation strategies. Following best practices, a lead facilitator and subject matter experts will help PCHHs explore and prepare protocols for implementation of LBC strategies while trained practice coaches will provide technical assistance around implementation at each site. CDPH has strong interest in integrating LBC strategies into PCHHs and will both mandate PCHH participation in the learning collaborative and encourage LBC implementation through additional funding. We will assess the process of adoption and implementation of LBC strategies using mixed methods. (2) Evaluate site-specific and system-wide effectiveness of integrated LBC strategies at improving sustained care and VS. Using a single-arm, pre–post trial design, we will assess if rates of retention in care and VS improve in the two years following ramp-up of LBC strategies. We will also examine contextual factors and implementation fidelity using mixed methods to explain variability in outcomes across PCHHs. (3) Assess implementation cost and sustainment of LBC strategies among PCHHs. We will examine implementation costs over time and plans for sustainment using mixed methods. Our proposal directly responds to RFA-AI-21-024 and is consistent with the NIH Office of AIDS Research’s high priority of implementation science to improve HIV service delivery and reduce disparities in treatment. Results from this study will facilitate the use of LBC strategies in new settings to reach PWH with complex needs.