Effectiveness of Peer Navigation to Link Released HIV+ Jail Inmates to HIV Care

摘要 寻求，测试和治疗模式认为，广泛，一致的抗逆转录病毒疗法（ART）治疗 可以降低社区中可传播的HIV RNA病毒载量水平。但有 在释放的艾滋病毒阳性被监禁人口中实施这一战略面临无数挑战， 释放后护理经常中断。具体而言，许多前囚犯未能与社区为基础的 艾滋病毒护理足够长的时间来维持病毒载量抑制，或者他们未能重新启动任何监禁前的联系。 因此，艾滋病毒阳性的前囚犯迫切需要干预措施，以改善他们在艾滋病毒护理中的保留。大多数现有 对监狱进行了研究;然而，监狱中的人更没有机会建立 最佳的抗逆转录病毒疗法方案，但在释放时面临同等的治疗中断。更多的人通过 监狱比监狱被监禁的人还面临着频繁的累犯，导致监狱和监狱之间的旋转门。 社会各界该提案的目标是调整现有的基于理论的干预措施，以最大限度地提高其 艾滋病毒阳性前囚犯的可行性和可接受性。我们将采用随机设计， 艾滋病毒阳性的前囚犯被分配到干预和176个对照组实施干预， 评估其有效性。这项研究将在洛杉矶释放的艾滋病毒阳性男性前囚犯中进行。 洛杉矶县监狱系统，世界上最大的城市监狱系统。拟议的干预措施将使用 个人提供的、以同伴为基础的学习方法，以消除艾滋病毒护理的障碍和促进因素 艾滋病毒感染者的监狱释放人员。 该提案有两个主要具体目标： 1.为了检查个人层面和结构层面的障碍，从监狱释放后的艾滋病毒护理，使用 与前囚犯、个案管理人员和艾滋病毒护理提供者进行形成性半结构化访谈; 利用我们获得的信息，为调整和定制干预措施提供信息， 改善与艾滋病毒阳性前囚犯的艾滋病毒护理的联系和保持; 2.使用两组实验RCT设计，以测试适应的基于同伴的健康系统导航 与通常的护理条件相比，艾滋病毒阳性囚犯出狱后的干预条件， 评估干预措施在改善与艾滋病毒护理的联系和保留方面的有效性， 报告的ART依从性和HIV RNA病毒载量抑制; 其次，我们将评估药物滥用的潜在调节作用， 药物滥用治疗的效果，该计划对累犯的影响，以及费用。 如果成功，具有成本效益，并作为一个更广泛的战略，为所有获释的囚犯，社区， 而刑满释放人员的回报可能会受益于整体社区病毒载量的减少，这可能会增加 除了改善前囚犯的健康状况外，还应加强现有的预防战略。

ABSTRACT The Seek, Test, and Treat model holds that broad, consistent treatment with antiretroviral therapy (ART) could lower the level of HIV RNA viral load in the community available for transmission. However, there are myriad challenges to implementing this strategy among released HIV+ incarcerated populations given the frequent discontinuity in care following release. Specifically, many ex-inmates fail to link to community-based HIV care long enough to sustain viral load suppression, or they fail to re-initiate any pre-incarceration linkage. Consequently, HIV+ ex-inmates urgently need interventions to improve their retention in HIV care. Most prior research has been conducted on prisons; however persons in jails have even less opportunity to establish optimal ART regimens, yet face equal disruption of treatment upon release. Far greater numbers pass through jails than prisons. Jailed persons also face frequent recidivism, resulting in a revolving door between jail and the community. The goal of this proposal is to adapt an existing, theory-based intervention to maximize its feasibility and acceptability to HIV+ ex-inmates. We will utilize a randomized design for 176 newly released HIV+ ex-inmates assigned to the intervention and 176 control subjects to implement the intervention and evaluate its effectiveness. The study will be conducted among HIV+ male ex-inmates released from the Los Angeles County Jail System, the largest municipal jail system in the world. The proposed intervention will use individually delivered, peer-based learning approaches to address barriers to and facilitators of HIV care retention among released HIV+ jail inmates. The proposal has two Primary Specific Aims: 1. To examine individual-level and structural-level barriers to HIV care after release from jail, using formative semi-structured interviews with ex-inmates, case managers, and HIV care providers; and to use the information we obtain to inform the adaptation and tailoring of an intervention designed to improve linkage with and retention to HIV care for HIV+ ex-inmates; 2. Using a two-group experimental RCT design, to test the adapted peer-based health system navigation intervention condition for HIV+ inmates upon release from jail compared to a usual care condition, and to evaluate the intervention's effectiveness at improving linkage with and retention in HIV care, self- reported ART adherence, and HIV RNA viral load suppression; Secondarily, we will assess the potential moderating effects of substance abuse, the potential mediating effects of substance abuse treatment, and the program's effects on recidivism, and costs. If successful, cost-effective, and adopted as a broader strategy for all released inmates, the community to which the ex-inmate returns may benefit from reduced overall community viral load, which could augment existing prevention strategies, in addition to improving the ex-inmates' health outcomes.