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

基本信息

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
项目类别：
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

项目摘要

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.

抽象的持续在艾滋病毒护理中保留对病毒抑制至关重要，但是经常患有艾滋病毒（PLWH）的人随着时间的流逝，过渡进出，使它们处于持续的病毒性和耐药性的高风险。甚至当PLWH损失后恢复后续行动（LTFU）时，将来再次成为LTFU的速度非常高的。我们来自赞比亚的初步数据表明，30％在6个月内再次成为LTFU，而50％在目前LTFU的人中，以前曾循环进出护理。护理重新接触的时间是因此，要干预这一高风险人群的关键时期，以及改善返回后护理的策略迫切需要打破持续不断的脱离自行车。返回护理后，PLWH经常报告是受到责骂，医疗保健工作者（HCW）延迟因依从性而引起的艺术重新生产，并且不始终如一监测病毒学反应，而PLWH可能仍然会遇到生活状况（例如，竞争义务，旅行远离家乡或社会心理因素），导致其最初的LTFU。 1）目标HCW行为（即，欢迎返回患者，及时重新定产）使用实践等实施策略促进，审计和反馈以及2）提供量身定制的PLWH支持服务，该服务是其最初的LTFU原因（例如，可以承诺扩展补充，转移协调，同行循环）。但是，要成功，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 HCW参加出席和行为改变策略，2）哪些支持服务优先考虑不同的障碍， 3）如何将活动集成到现有的工作流程中。该R34提案将建立必要的基础用于实施多组分重新参与策略，以支持返回后持续的重新接触艾滋病毒护理。在AIM 1A中，我们评估了患者和HCW的需求和偏好患者半结构化访谈（n = 20）以及与HCW和诊所领导层的焦点小组讨论（4个FGD， n = 8-10）。在AIM 1B中，我们进行离散选择实验（200 plWh，100 HCW）来量化相对对我们的重新参与策略的内容和属性的偏好。在AIM 2中，我们承担了人类与主要利益相关者（PLWH，HCWS，诊所领导，卫生部）与关键利益相关者的中心设计过程共同开发多组分重新参与策略的内容和功能，重点是1）改进患者的重新接触经验，2）优化艺术重新生产和返回后病毒负荷监测，以及 3）提供针对个人LTFU特定原因的量身定制服务。在AIM 3中，我们将驾驶在赞比亚卢萨卡的一个城市和一个乡村诊所制定了战略。我们将使用混合方法评估实施（例如，可接受性，适当性），服务提供（例如，艺术的时间起始，病毒载荷监测）和临床结果（例如，在返回）。该提案的结果将直接通知将来的R01，以正式测试此健康系统干预对于在II型混合实施效应聚类随机试验中重新接触HIV护理的患者。