Optimizing Care Delivery to Support Reengagement in PLWH Returning to HIV Care after Treatment Lapses in Zambia

优化护理服务，支持赞比亚治疗失败后重新接受艾滋病毒感染者护理

• 批准号: 10484440
• 负责人: Aaloke Mody
• 金额: $ 21.17万
• 依托单位: WASHINGTON UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-08-10 至 2025-07-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10484440
• 关键词: Address; Adherence; Africa South of the Sahara; Aftercare; Attitude; Back; Behavior; Caring; Clinic; Clinical; Cluster randomized trial; Collaborations; Counseling; Data; Development; Drug resistance; Effectiveness; Ensure; Feedback; Focus Groups; Foundations; Future; HIV; Health; Health Personnel; Health system; Home; Human; Individual; Infectious Diseases Research; Interruption; Intervention; Interview; Lead; Leadership; Life Experience; Methods; Monitor; Morbidity - disease rate; Nurses; Outcome; Patient Care; Patient-Focused Outcomes; Patients; Persons; Physicians; Process; Protocols documentation; Provider; Psychosocial Factor; Qualitative Methods; Reporting; Research; Research Infrastructure; Research Personnel; Rural; Services; Structure; Testing; Time; Training; Travel; Universities; Viral; Viral Load result; Viremia; Washington; Zambia; behavior change; care delivery; critical period; design; effectiveness implementation study; evidence base; experience; experimental study; follow-up; high risk; high risk population; human centered design; implementation evaluation; implementation framework; implementation strategy; improved; improved outcome; mortality; patient population; peer; preference; prevent; programs; prototype; public health priorities; response; service delivery; transmission process

ABSTRACT Sustained retention in HIV care is critical for viral suppression, but people living with HIV (PLWH) frequently transition in and out of care over time, putting them at high risk for ongoing viremia and drug resistance. Even when PLWH return to care after loss to follow-up (LTFU), rates of becoming LTFU again in the future are very high. Our preliminary data from Zambia suggests that 30% become LTFU again within 6 months, and that 50% of those who are currently LTFU have previously cycled in and out of care. The time of reengagement in care is thus a critical period to intervene in this high-risk population, and strategies to improve post-return care delivery are urgently needed to break ongoing cycles of disengagement. After returning to care, PLWH often report being scolded, health care workers (HCW) delay ART re-initiation due to adherence concerns and do not consistently monitor virologic response, and PLWH likely still experience the life situations (e.g., competing obligations, travel away from home, or psychosocial factors) that led to their initial LTFU. Strategies to 1) target HCW behaviors (i.e., welcoming returning patients, prompt ART re-initiation) using implementation strategies such as practice facilitation and audit and feedback and 2) offer PLWH support services tailored to their initial reasons for LTFU (e.g., extended refills, transfer coordination, peer-navigation) may be promising. To be successful, however, we need to understand how to effectively implement these approaches into existing care, including 1) how to engage HCWs in attitude- and behavior-change strategies, 2) what support services to prioritize for different barriers, and 3) how to integrate activities into existing workflows. This R34 proposal will build the necessary foundation for implementing a multicomponent reengagement strategy to support sustained reengagement after returning to HIV care. In Aim 1a, we assess patient and HCW needs and preferences for reengagement strategies with patient semi-structured interviews (n=20) and focus group discussions with HCWs and clinic leadership (4 FGDs, n=8-10 each). In Aim 1b, we conduct discrete choice experiments (200 PLWH, 100 HCWs) to quantify relative preferences for the contents and attributes for our reengagement strategy. In Aim 2, we undertake a human- centered design process that engages key stakeholders (PLWH, HCWs, clinic leadership, Ministry of Health) in co-developing the content and features of a multicomponent reengagement strategy focused on 1) improving the patient reengagement experience, 2) optimizing ART re-initiation and viral load monitoring post-return, and 3) providing tailored services that target individuals’ specific reasons for LTFU. In Aim 3, we will pilot the developed strategy at one urban and one rural clinic in Lusaka, Zambia. We will use a mixed-methods approach to assess the implementation (e.g., acceptability, appropriateness), service delivery (e.g., time to ART re- initiation, viral load monitoring), and clinical outcomes (e.g., retention and viral suppression at 6 months post- return). Results from this proposal will directly inform a future R01 to formally test this health-system intervention for patients reengaging in HIV care in a Type II hybrid implementation-effectiveness cluster randomized trial.

抽象的 持续保留艾滋病毒护理对于抑制病毒至关重要，但艾滋病毒感染者 (PLWH) 经常 随着时间的推移，他们进入和退出护理，使他们面临持续病毒血症和耐药性的高风险。甚至 当 PLWH 在失访 (LTFU) 后返回护理时，未来再次成为 LTFU 的比率非常高 高的。我们来自赞比亚的初步数据表明，30% 的人在 6 个月内再次成为 LTFU，而 50% 目前接受 LTFU 治疗的患者中，有 % 之前曾循环进出护理机构。重新接受护理的时间是 因此，这是对这一高危人群进行干预的关键时期，也是改善回国后护理服务的战略 迫切需要打破持续的脱离接触循环。返回护理中心后，艾滋病病毒感染者经常报告说 受到责骂的医护人员 (HCW) 由于依从性问题而延迟重新启动 ART，并且没有始终如一地 监测病毒学反应，感染者可能仍会经历生活状况（例如，相互竞争的义务、旅行 离开家或社会心理因素）导致他们最初的 LTFU。 1) 针对医护人员行为的策略 （即欢迎返回的患者、及时重新启动 ART）使用实践等实施策略 促进、审计和反馈，2) 根据 PLWH 最初接受 LTFU 的原因提供量身定制的支持服务 （例如，延长补充、转移协调、同行导航）可能是有希望的。然而，为了获得成功，我们 需要了解如何有效地将这些方法实施到现有护理中，包括 1) 如何参与 医护人员的态度和行为改变策略，2) 针对不同障碍优先考虑哪些支持服务， 3) 如何将活动集成到现有工作流程中。 R34 提案将奠定必要的基础 实施多组成部分的重新接触战略，以支持返回后的持续重新接触 艾滋病毒护理。在目标 1a 中，我们评估患者和医护人员对重新参与策略的需求和偏好， 患者半结构化访谈 (n=20) 以及与医护人员和诊所领导层的焦点小组讨论 (4 FGD, n=8-10 个）。在目标 1b 中，我们进行离散选择实验（200 名 PLWH、100 名医护人员）来量化相对 对我们重新参与策略的内容和属性的偏好。在目标 2 中，我们开展了一项人力- 以中心为中心的设计流程，让主要利益相关者（艾滋病毒感染者、医护人员、诊所领导、卫生部）参与其中 共同开发多部分重新参与策略的内容和特征，重点关注 1) 改进 患者重新参与体验，2) 优化 ART 重新启动和返回后病毒载量监测，以及 3) 针对个人 LTFU 的具体原因提供量身定制的服务。在目标 3 中，我们将试点 为赞比亚卢萨卡的一家城市诊所和一家农村诊所制定了战略。我们将使用混合方法 评估实施情况（例如，可接受性、适当性）、服务交付（例如，重新接受 ART 的时间） 启动、病毒载量监测）和临床结果（例如，6个月后的保留和病毒抑制） 返回）。该提案的结果将直接告知未来的 R01，以正式测试该卫生系统干预措施 在 II 型混合实施效果集群随机试验中，针对重新接受艾滋病毒护理的患者。