Ending the HIV Epidemic with Equity: An All-facility Intervention to Reduce Structural Racism and Discrimination and Its Impact on Patient and Healthcare Staff Wellbeing

项目摘要 这项研究的范围是从事瑞安白色艾滋病毒/艾滋病计划（RWHAP）资助的组织在结束 美国南部/东部的艾滋病毒流行（ETHE）地区共同开发利用evi的情景响应计划， 采取知情干预措施，减少对黑人、土著人、 有色人种（BIPOC）艾滋病毒感染者（PLH）和BIPOC医疗工作者。SRD直接影响获得 为BIPOC提供医疗保健，包括在整个预防过程中参与艾滋病毒服务 和关怀.拟议的干预措施名为TRansends，借鉴了以证据为基础的卫生政策加 (HP+）已证明有效的“全面”设施艾滋病毒污名减少干预和接触理论 减少种族歧视的重要性。TRansends针对诊所的组织（例如，反种族 以及多样性、公平和包容政策）和制度（例如，员工态度/行为）水平 患者（例如，经验和感知的歧视，艾滋病毒护理，心理健康）的结果和工作人员（例如，工作 幸福，在个人层面。在目标1中，我们将从ETHE地区严格选择6家诊所， 确认全面承诺拆除SRD（第3-9月）。在目标2中，基线评估后（N=180;月 11-12），我们将进行SRD减少干预的阶梯式楔形分组随机试验。在每个 这3个步骤中，两个随机诊所将接受TRAnscends。干预措施将支持诊所1）识别- 制定/制定组织一级的反种族主义政策和做法（例如，种族主义行为的明确定义，ade- （包括培训和监测系统，以及对建设性纠正的迅速反应），以减少SRD， 增加BIPOC患者和提供者/工作人员基于种族的公平性，以及2）向所有人提供针对种族的培训 工作人员（例如，SRD的历史，偏见和歧视的健康后果，文化谦卑，交叉dis- 种族、族裔、性行为和性别等因素共同构成犯罪）。每个集群都将接受干预 6个月，从群集组1（13-18个月）开始，然后是群集组2（19-24个月）和群集组3（18个月 25-30）。在目标3中，我们将使用CFIR评估多层次的结果，包括在组织内（初级）， SRD指数的玛丽结果-对使命/愿景声明、反种族主义政策、劳动力多样性、平等、 ty和包容性[DEI]，诊所环境），系统（提供者/工作人员态度的次要结果;行为; DEI指标）和个体患者水平（临床水平HIV指标的三级结局， 国家，医疗不信任，焦虑，抑郁和创伤）的结果。评估将每6天进行一次 个月，随机分配到第二或第三步的诊所在进行间- 预防（最终数据收集在第49个月）。BIPOC患者在诊所将在每个调查，因为- （N= 2，100）。调查结果将产生一个手册，用于实施整个设施的SRD减少过程， 内容（mos 52-60）。其他由农村卫生保健方案资助的诊所和设施，为边缘化群体提供服务， 采用这种手动但适应性强的干预包来支持BIPOC。

Project Summary The scope of this study is to engage Ryan White HIV/AIDS Program (RWHAP) funded organizations in Ending the HIV Epidemic (ETHE) areas in the South/East US to co-develop context-responsive programs utilizing evi- dence-informed interventions to reduce structural racism and discrimination (SRD) against Black, Indigenous, People of Color (BIPOC) living with HIV (PLH) and BIPOC healthcare workers. SRD directly impacts access to and uptake of healthcare for BIPOC, including engagement in HIV services across the continuum of prevention and care. The proposed intervention, titled TRAnscenDS, draws on the evidence-based Health Policy Plus (HP+) ‘total’ facility HIV stigma-reduction intervention and Contact Theory, which have demonstrated efficacy in reducing race-related intergroup prejudice. TRAnscenDS targets the clinics’ organizational (e.g., anti-racist and diversity, equity and inclusion [DEI] policies) and systems (e.g., staff attitudes/behaviors) levels to affect patient (e.g., experienced and perceived discrimination, HIV care, mental health) outcomes and staff (e.g., job satisfaction) wellbeing, at the individual level. In Aim 1, we will rigorously select 6 clinics from ETHE areas evi- dencing full commitment to dismantling SRD (mos 3-9). In Aim 2, after a baseline assessment (N=180; mos 11-12), we will conduct a stepped wedge cluster randomized trial of the SRD reduction intervention. At each of the 3 steps, two randomized clinics will receive TRAnscenDS. The intervention will support clinics to 1) identi- fy/create organizational-level anti-racist policies and practices (e.g., clear definitions of racist behavior, ade- quate training and monitoring systems, and prompt responses for constructive redress) to reduce SRD and increase race-based equity for BIPOC patients and provider/staff, and 2) deliver race-specific trainings to all staff (e.g., history of SRD, health consequences of bias and discrimination, cultural humility, intersectional dis- crimination at the confluence of race, ethnicity, sexuality and gender). Each cluster will receive the intervention for 6 mos, starting with Cluster Group 1 (mos 13-18), followed by Cluster Groups 2 (mos 19-24) and 3 (mos 25-30). In Aim 3, we will evaluate multi-level outcomes using the CFIR, including within the organization (pri- mary outcome of SRD Index – ratings of mission/vision statements, anti-racist policy, workforce diversity, equi- ty and inclusion [DEI], clinic environment), systems (secondary outcomes of provider/staff attitudes; behavior; DEI indicators), and individual patient level (tertiary outcomes of clinic-level HIV indicators, reports of discrimi- nation, medical distrust, anxiety, depression, and trauma) outcomes. Assessments will take place every 6 months, with the clinics randomized to the second or third step having multiple assessments before the inter- vention (with final data collection being in month 49). BIPOC patients at the clinics will be surveyed at each as- sessment (N=2,100). Findings will yield a manual for implementing total-facility SRD-reduction processes and content (mos 52-60). Other RWHAP-funded clinics and facilities serving marginalized groups may be able to adopt this manualized, yet highly adaptable intervention packet to support BIPOC.