Overcoming Barriers to HIV/AIDS Care and ART Initiation

描述（由申请人提供）：该提案概述了一个为期五年的职业发展和研究计划，以培养候选人作为一个独立的流行病学调查员，专注于在国际环境中的结果研究。候选人在HIV-1风险因素和传播方面的优秀学术表现和国际工作，包括预防干预措施的普遍性，证明了他在流行病学方法和应用研究方面的专业知识。作为一名博士生，他领导了一项针对肯尼亚不和谐夫妇的大型前瞻性队列研究的流行病学设计和分析。这一研究经验得到了博士后奖学金的加强，他调查了及时启动抗逆转录病毒治疗（ART）的障碍，并开发了风险因素分布对干预试验普遍性影响的数学模型。这个K 01奖将使候选人将这种背景融入到一个新的调查线上的行为干预措施的实施，以促进艾滋病毒/艾滋病的护理和治疗。候选人将得到专家导师的支持，以提供指导，并确保该项目的成功。丰富的制度环境将支持他的职业发展。研究报告在撒哈拉以南非洲的自愿咨询和检测（VCT）中心，半数HIV-1检测呈阳性的患者未能与艾滋病毒/艾滋病护理联系起来。这突出了卫生系统的一个严重缺陷，可以通过干预措施来解决，以改善与护理的联系，从而减缓疾病进展，加速ART的启动，并改善健康结果。我们假设，实施科学的方法将产生一揽子干预措施，以改善与护理和治疗的联系，这将是在非洲各地迅速扩展。我们将测试行为干预，并评估新的床旁（POC）CD 4检测，以改善与护理的联系。具体目标是（1）确定基于VCT的CD 4计数检测干预措施，单独或与同伴咨询相结合，是否改善了与艾滋病毒/艾滋病护理的联系;（2）评估干预措施对ART启动的影响;（3）确定与延迟返回结果的常规检测相比，使用新POC检测快速返回CD 4结果是否改善了与护理的联系。首先，我们将对患者、咨询师和医疗服务提供者之间的护理障碍进行快速评估，以完善干预措施（基于VCT的CD 4计数和同伴咨询）。然后，我们将从VCT招募450名HIV阳性者，并随机分配三分之一接受标准咨询和转诊，三分之一在VCT接受CD 4检测，两周后通过电话返回结果，三分之一接受相同的CD 4检测结合同伴咨询。我们将招募另外150名参与者接受POC CD 4检测，并快速返回结果，并将其与护理率的联系与两周后接受CD 4结果的人进行比较。这些综合调查将全面了解艾滋病毒/艾滋病适当护理的障碍，并导致新的干预措施，以在应用环境中取得可衡量的成果。通过该奖项，候选人将获得实施科学的新专业知识，并将成为一名专注于资源有限环境中健康干预措施的独立调查员。

DESCRIPTION (provided by applicant): This proposal outlines a five-year career development and research plan to train the candidate as an independent epidemiologic investigator focused on outcomes research in international settings. The candidate's strong academic performance and international work on HIV-1 risk factors and transmission, including generalizability of prevention interventions, demonstrates his expertise in epidemiologic methodology and applied research. As a doctoral candidate, he led the epidemiologic design and analysis of a large prospective cohort study of discordant couples in Kenya. This research experience was enhanced by a postdoctoral fellowship in which he investigated barriers to timely initiation of antiretroviral therapy (ART) and developed mathematical models for the impact of the distribution of risk factors on generalizability of intervention trials. This K01 award will enablethe candidate to integrate this background into a new line of investigation on the implementation of behavioral interventions to promote HIV/AIDS care and treatment. The candidate will be supported by expert mentors to provide guidance and ensure the success of this project. An enriching institutional environment will support his career development. RESEARCH PLAN. Half of patients testing positive for HIV-1 at voluntary counseling and testing (VCT) centers in Sub-Saharan Africa fail to link with HIV/AIDS care. This highlights a critical deficiency in the health system that can be addressed with interventions to improve linkage to care that will slow disease progression, accelerate ART initiation, and improve health outcomes. We hypothesize that an implementation science approach will produce a package of interventions to improve linkage to care and treatment that will be rapidly scalable across sites in Africa. We will test a behavioral intervention and evaluate new point-of-care (POC) CD4 testing to improve linkage to care. The specific aims are to (1) determine if a VCT-based intervention of CD4 count testing, alone or in combination with peer counseling, improves linkage to HIV/AIDS care; (2) assess the impact of the intervention on ART initiation; and (3) determine if rapid return of CD4 results using new POC testing improves linkage to care compared to conventional testing with delayed return of results. First, we will conduct a rapid assessment of barriers to care among patients, counselors, and health providers to refine the intervention (VCT-based CD4 counts and peer counseling). We will then recruit 450 HIV-positive individuals from VCTs and randomize a third to standard counseling and referral, a third to receive CD4 testing at the VCT with results return by phone after two weeks, and a third to receive the same CD4 testing combined with peer counseling. We will recruit an additional 150 participants to receive POC CD4 testing with rapid return of results and compare their linkage to care rates to those receiving CD4 results after two weeks. These combined investigations will create a comprehensive understanding of obstacles to appropriate HIV/AIDS care and result in new interventions to achieve measurable outcomes in applied settings. Through this award the candidate will gain new expertise in implementation science and will become an independent investigator focused on health interventions in resource-limited settings.