Interventions to decrease HIV infectiousness in Uganda

描述（由申请人提供）：本申请，干预措施，以减少艾滋病毒在乌干达的传染性，响应美国国立卫生研究院主任的研究机会（RC-4）在全球卫生主题。需要新的、具有成本效益的战略，以便在非洲有效地提供经证实的艾滋病毒预防和治疗服务，对人口艾滋病毒发病率产生重大影响。我们认为，通过有针对性地向艾滋病毒阳性者提供人口层面的艾滋病毒预防和护理服务，通过增加对艾滋病毒阳性状况及其相关行为改变的了解，通过启动抗逆转录病毒治疗（ART）以及预防和治疗疟疾等合并感染来降低艾滋病毒感染率，可以减少社区中的艾滋病毒传播。以家庭为基础的艾滋病毒咨询和检测方案（HBCT）已经实现了对艾滋病毒血清状况的大规模了解。我们将建立在HBCT平台（“HBCT-plus”）上，为艾滋病毒阳性者提供有针对性的诊断，预防和治疗服务以及行为咨询，以减少艾滋病毒的传染性，这将增强我们在乌干达的预防方案项目（MP-3）研究方法。我们将在乌干达艾滋病毒高流行地区的5 000个家庭中实施HBCT+，通过护理点（POC）CD 4检测，按照乌干达的指导方针以及预防和治疗所有艾滋病毒+患者的合并感染，将艾滋病毒+患者分类为抗逆转录病毒治疗。我们将提供预防为积极的风险降低咨询和不和谐的夫妇咨询，以减少风险行为。我们将进行为期一年的季度随访，以优化临床干预措施的采用，并评估风险行为和耻辱。HBCT-plus成功的指标将影响：1）社区病毒载量（12个月内社区平均HIV血浆病毒载量），人群水平HIV感染性的标志物，和2）HIV传播潜力，HIV+人群中病毒载量和性行为的综合指标，HIV-或血清状态未知的伴侣，对HIV传播影响最大。具体目标：1）证明HBCT+的可行性，包括艾滋病毒检测，POC CD 4检测以将艾滋病毒阳性者分类护理，以及预防阳性和不一致的夫妇咨询，在一年内向乌干达的5 000个家庭提供，基于艾滋病毒阳性者中>90%的检测和>80%的护理联系。2)通过评估HBCT-plus前后社区病毒载量和HIV传播潜力，衡量HBCT-plus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阳性者进行积极预防咨询前后，测量向伴侣和家人的披露情况、伴侣的艾滋病毒检测、安全套使用情况、性行为频率和伴侣数量。4)通过在社区进行概率抽样调查，评估HBCT-plus对社区危险行为、艾滋病检测态度和污名化的影响。5)确定HBCT的增量成本和HBCT-plus中用于促进艾滋病毒护理和咨询的其他组成部分，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.