Interventions to decrease HIV infectiousness in Uganda

描述(由申请人提供)：这项申请名为减少乌干达艾滋病毒传染性的干预措施，响应了国家卫生研究所所长在全球卫生主题下的研究机会(RC-4)。需要新的、具有成本效益的战略，以便在非洲有效地提供经过验证的艾滋病毒预防和治疗服务，从而对人口艾滋病毒发病率产生重大影响。我们假设，通过在人群中有针对性地向艾滋病毒携带者提供艾滋病毒预防和护理服务，通过增加对艾滋病毒感染状况的了解以及相关的行为变化，并通过启动抗逆转录病毒疗法(ART)以及预防和治疗疟疾等混合感染，可以减少社区中艾滋病毒的传播。以家庭为基础的艾滋病毒咨询和检测计划，HBCT，已经实现了对艾滋病毒血清状态的大规模了解。我们将在HBCT平台(“HBCT+”)的基础上，为HIV+患者提供有针对性的诊断、预防和治疗服务，并提供行为咨询，以降低艾滋病毒的传染性，这将加强我们在乌干达的预防方法项目(MP-3)研究。我们将在乌干达艾滋病毒高发区的5000个家庭中实施HBCT-plus，按照乌干达指南对艾滋病毒+患者进行分流治疗，并预防和治疗所有艾滋病毒+患者的合并感染。我们将提供预防换积极、减少风险咨询和不和谐夫妻咨询，以减少危险行为。我们将进行为期一年的季度跟踪访问，以优化临床干预措施的接受，并评估危险行为和污名。HBCT-plus成功的衡量标准将对以下方面产生影响：1)社区病毒载量(社区内12个月的平均艾滋病毒血浆病毒载量)，这是人口水平艾滋病毒传染性的标志；以及2)艾滋病毒传播潜力，这是对艾滋病毒传播有最大影响的艾滋病毒+感染者或血清状态不明的伴侣中病毒载量和性行为的综合衡量。具体目标：1)证明HBCT-PLUS的可行性，包括艾滋病毒检测、对艾滋病毒携带者进行分类护理的POC CD4检测，以及在一年内向乌干达5000个家庭提供阳性预防和不和谐夫妇咨询，其基础是&>90%的检测接受率和&>80%与艾滋病毒携带者之间的护理联系。2)通过评估HBCT+前后社区病毒载量和HIV传播潜力，衡量HBCT+对社区HIV传播风险的影响。3)通过HBCT-PLUS对新发现的艾滋病毒感染者在阳性预防咨询前后向伴侣和家人披露情况、对伴侣进行艾滋病毒检测、避孕套的使用、性行为频率和伴侣数量进行衡量。4)通过社区概率抽样调查，评估HBCT-plus对社区危险行为、对HIV检测的态度和污名的影响。5)确定HBCT和HBCT-PLUS中促进艾滋病毒护理和咨询的其他组成部分的增量成本，并估计社区病毒载量减少的成本效益。

DESCRIPTION (provided by applicant): This application, Interventions to decrease HIV infectiousness in Uganda, responds to the NIH Director's Opportunity for Research (RC-4) within the Global Health theme. Novel, cost-effective strategies are needed to efficiently deliver proven HIV prevention and treatment services in Africa to have a substantial impact on population HIV incidence. We posit that HIV transmission in a community can be reduced through targeted, population-level delivery of HIV prevention and care services to HIV+ persons, through increasing knowledge of HIV+ status with associated behavior change and reducing HIV infectiousness through initiation of antiretroviral therapy (ART), and prevention and treatment of co-infections such as malaria. Home-based HIV counseling and testing programs, HBCT, have achieved large scale knowledge of HIV serostatus. We will build on the HBCT platform ("HBCT-plus") with targeted diagnostic, preventive, and treatment services for HIV+ persons and behavioral counseling to reduce HIV infectiousness, which will augment our Methods of Prevention Program Project (MP-3) research in Uganda. We will implement HBCT-plus in 5000 households in a high HIV prevalence area in Uganda with point-of-care (POC) CD4 testing to triage HIV+ persons to ART following Uganda guidelines and prevention and treatment of co-infections for all HIV+ persons. We will deliver prevention-for-positives risk-reduction counseling and discordant couples counseling to reduce risk behaviors. We will conduct quarterly follow-up visits for one year to optimize uptake of clinical interventions and to assess risk behaviors and stigma. Measures of success of HBCT-plus will be impact on: 1) community viral load (average HIV plasma viral load in the community over 12 months), a marker of population-level HIV infectiousness, and 2) HIV transmission potential, a composite measure of viral load and sexual behavior among HIV+ persons with HIV- or unknown serostatus partners, who have the greatest impact on HIV spread. Specific Aims: 1) Demonstrate feasibility of HBCT-plus, with HIV testing, POC CD4 testing to triage HIV+ persons to care, and prevention-for-positives and discordant couples counseling, delivered to 5000 households in Uganda in one year, based on >90% uptake of testing and >80% linkage to care among HIV+ persons. 2) Measure the impact of HBCT-plus on HIV transmission risk in the community through assessment of community viral load and HIV transmission potential before and after HBCT- plus. 3) Measure disclosure to partners and family, HIV testing of partners, condom use, sexual frequency, and number of partners before and after positive prevention counseling for newly-identified HIV+ persons through HBCT-plus. 4) Evaluate the effect of HBCT-plus on community risk behaviors, attitudes about HIV testing, and stigma through a probability sample survey in the community. 5) Determine the incremental costs of HBCT and additional components in HBCT-plus for facilitated HIV care and counseling, and estimate the cost-benefit of community viral load reduction.