HIV Care Utilization: A theory-based approach to retention in care

描述(由申请人提供)：由于个人和社区层面的病毒载量负担增加，对接受护理的艾滋病毒阳性患者个人和周围社区来说，不一致地使用艾滋病毒医疗服务可能会导致可怕的后果。虽然最近为将艾滋病毒携带者纳入护理和重新参与失去护理的艾滋病毒携带者进行了紧张的努力，但对一旦开始或重新开始影响艾滋病毒护理持续维持的因素知之甚少，尽管这一群体特别容易出现额外的并发症(例如由于间歇性坚持而产生的抵抗力)，以及他们提供的以临床为基础的干预的机会之窗。拟议的工作旨在通过开发和评估基于理论的护理留存模式和简短的有针对性的干预措施来支持那些疲弱参与的人留住护理，从而解决文献中的这一差距和未得到满足的服务相关需求。我们将成熟的信息-动机-行为技能(IMB)模型应用于HIV医学中的保留，用于两项研究。这一IMB模型被用来识别核心心理-社会过程，根据信息、动机和行为技能的类型，通过识别这些心理过程中潜在的可修改的缺陷，这些心理过程可以用来提供与保留相关的干预策略，从而维持一段时间内定期使用艾滋病毒医疗护理所需的这些心理-社会过程。在研究1中，我们将使用基于IMB的横向护理保持测量来测试该模型，并在市中心诊所样本中确定与护理保持相关的信息、动机和行为技能的关键水平。具体地说，我们的第一个目标是测试在市中心诊所人群中保留艾滋病毒医疗服务的信息-动机-行为技能模型。研究2将试行一项基于密集单时段动机访谈的干预措施，它使用基于IMB模型的筛选器来确定基于个体模型的护理保留障碍，以患者为中心进行讨论，目标是特别针对在过去一年半内间隔在艾滋病毒护理中的患者遵守下一次诊所就诊。根据干预后6个月护理利用的客观指数，以及干预后信息、动机和行为技能的即时变化，将根据相同队列内的时间和注意力控制条件来评估干预。因此，我们的第二个目标是设计、实施和评估一项基于诊所的概念验证干预措施，旨在解决IMB模型核心决定因素在护理中的保留，并在一个微不足道的市中心样本中促进护理中的保留。拟议的项目将对这一调查领域作出独特贡献，并对控制个人和社区一级病毒负担的可行干预方法产生实际影响。 公共卫生相关性：拟议的项目将测试艾滋病毒医疗保健中留存的信息动机行为技能模型，并评估一种简短的有针对性的干预措施，通过改进该模式确定的核心因素来促进留存，该模式提供了一个可以很容易转化为有效干预方法的全面留存模式，从而为这一研究领域做出了独特贡献。以理论为基础的针对性干预的试点对扩大我们对保留护理的有效干预的理解以及为促进在临床护理点提供参与的潜在战略提供指导都有意义。为了改善健康和大幅减少对个人和公共健康至关重要的病毒载量，这种加强和维持护理的努力是必要的。

DESCRIPTION (provided by applicant): Inconsistent use of HIV medical care has been associated with potentially dire outcomes for both the individual HIV positive patient in care and the surrounding community due to increased burden of individual- and community-level viral load. While there have been recent intense efforts to enroll people living with HIV (PLWH) into care and to re-engage PLWH lost to care, less is known about factors influencing sustained maintenance in HIV-care once initiated or re-initiated, despite this group's particular vulnerability to additional complications (such as resistance due to intermittent adherence) and the window of opportunity for clinic- based intervention that they present. The proposed work aims to address this gap in the literature and unmet service-related needs through the development and evaluation of a theory based model of retention in care and a brief targeted intervention to support retention in care for those tenuously engaged. We adapt the well- established the Information-Motivation-Behavioral Skills (IMB) model to retention in HIV medical for use in two studies. This IMB model is used to identify the core psycho-social processes in terms of the types of information, motivation, and behavior skills needed to sustain regular use of HIV medical care over time by identifying potentially modifiable deficits in these psychological processes that can be used to inform retention- related intervention strategies. In Study 1 we will use a cross-sectional IMB-based measure of retention in care to test the model and identify the critical levels of information, motivation, and behavioral skills related to retention in care within an inner-city clinic sample. Specifically, our first aim is to test an Information- Motivation- Behavioral Skills Model of retention in HIV medical care in an inner-city clinic population. Study 2 will pilot an intensive single-session motivational-interviewing based intervention that uses an IMB- model based screener to identify individual model-based barriers to retention in care to tailor the patient- centered discussion targeting adherence to the next clinic visit specifically for patients who have gapped in HIV care over the last year and a half. This intervention will be evaluated against a time and attention control condition within the same cohort on objective indices of care utilization six months post intervention, as well as on immediate post-intervention changes in information, motivation, and behavioral skills. Thus, our second aim is to design, implement, and evaluate a proof-of-concept clinic-based intervention designed to address core IMB model determinants of retention in care, and promote retention in care in a tenuously engaged inner-city sample. The proposed project will contribute uniquely to this area of inquiry and have practical implications for viable intervention approaches for controlling individual- and community-level viral burden. PUBLIC HEALTH RELEVANCE: The proposed project will test an Information Motivation Behavioral Skill model of retention in HIV medical care and evaluate a brief targeted intervention to promote retention in care via improvements in the core factors identified by this mode, which uniquely contributes to this area of research by providing a comprehensive model of retention that can be easily translated to effective intervention approaches. The pilot of the targeted theory-based intervention has implications for both extending our understanding of effective interventions for retention in care as well as for providing guidance for potential strategies to promote engagement delivered at the point of clinical care. Such efforts to enhance and sustain retention in care are necessary to achieve improved health and significant reductions in viral load critical to individual and public health.